Coverage agreements: How they affect urology billing

Don’t charge for seeing another urologist’s patient if reciprocal arrangement is in place



Can I charge for hospital visits if I see another urologist’s post-surgical patient who is still in the global period (for instance, when they’re on call and round on many of these patients)? Or is it considered part of the surgery?


We will have to give you two answers to this question. The first answer is no, if you are in a reciprocating coverage arrangement with the other urologist—in other words, the other urologist sees your patients postoperatively when you are out of town and you see the other urologist’s patients when he/she is out of town. Even if the coverage agreement is not a formal, signed agreement, we would not charge for the visits.

The second answer is yes, if you are not in a coverage arrangement with the other urologist. For example, if a patient was operated on by another urologist and you were asked to see the patient for any reason, then you can charge for that hospital visit. Or, if the patient had been operated on by a urologist  elsewhere and you were seeing the patient postoperatively in the hospital or in the office, you should charge for your services and no modifier is needed.


What code would be used for image fusion regarding prostate magnetic resonance imaging and transrectal ultrasound for targeted biopsy? This is currently available under an Institutional Review Board approval only. When and how will it be available for general clinical use and for reimbursement (for use with the Artemis prostate imaging instrument [Eigen, Grass Valley, CA])?


As with any new technology, we often have to wait for CPT to adopt new codes that accurately describe the services provided, wait for a value to be assigned that will reimburse for the services, and/or wait for the coverage policies to be adopted. Although the system is designed to follow a step method, we have all seen that coverage and payment may precede the establishment of a code and value.

We did not locate a code or coverage policy that clearly applies to the use of image fusion with prostate biopsy ultrasound guidance. In today’s health care environment, coverage, coding, and payment for new technology are not automatic. Any new technology has to demonstrate clinical efficacy supported in peer-reviewed literature and have FDA approval, if applicable, to be included in CPT.

 Additionally, with many new technologies, payers are beginning to demand cost efficiency for a new procedure or service before they will cover it. We assume the manufacturer and those interested in the service you are describing are pursuing these goals.

 In the short term, the following codes may be applicable to the service you describe:

76942: Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

76376: 3-D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post processing on an independent workstation

76377: 3-D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post processing on an independent workstation

77021: Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation.

Without further information on the system and its use, we cannot comment directly on whether the codes above are applicable and/or paid for when using the device.